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Dr. Aaron Silver Fox Doc
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Case Presentation: Though I’ve summarized this a bit, the presentation itself is credited to the NEJM in an article called A Mysterious Death, by Dr. David Oldach et al. Imagine you’re attending physicians in the infirmary of a babylonian king’s palace in the 4th century BCE. You’re leaning against the chart rack which has stone tablets or whatever they used at the time to keep records to accurately bill ancient Babylonian patients… You’re looking all cool drinking your first cup of tea for the shift. Actually beer might have been the drink of choice for the time. Then your resident wants to present a new admission. A 32 year old male with chief complaint of upper abdominal pain and fever. He was recently in his normal state of health until he wasn’t. The other night he was enjoying 12 pints of wine, an activity which he said he did in moderation from time to time. The next day, he developed fatigue and generalized body aches. He had a similarly volumetric bucket amount of wine and developed sharp RUQ abdominal pain which caused him to “cry out” but then subsided. His abdomen remained tender to the touch in the area. Later he developed chills, sweats, and fever which continued into the following day. He’s already tried bathing in cool water and drinking and he did start to feel better after three days. His fever came back, however, and now he had rigors, no appetite, and worsening fatigue over the prior two days. By the sixth day of illness, and further cool baths and drinking wine to quench his thirst, he is brought to you with a severely high fever, unable to speak, and seeming to only be able to make minimal movements of his hands and eyes. Past medical history incidentally notable for penetrating trauma to the right side of his chest, resulting in a hemopneumothorax. Additional penetrating wounds to his thigh and a traumatic brain injury. Social history notable for occasional alcohol use. The patient lives in northern Greece and has been active in military service. He has traveled extensively as of late, returning from India. He’s been married a few times and does occasionally have male sexual partners, one of whom recently died from fever and illness of unspecified nature. His mother and brother have no reported health problems. His father did pass away from an acute case of murder secondary to being a Macedonian ruler in the 4th century BCE. The patient is a non-smoker. On exam he’s a well-built dude who appears uncomfortable. He’s sweating and febrile. He’s breathing slow and deep respirations. He only moves his eyes and hands slightly when you speak to him. No rashes or jaundice. He seems weak all over, severely so. Well healed wound to right chest wall noted. The resident physician says that the clinical course was complicated on day 11 of admission when the patient’s respirations became shallow and became dead after slipping into a coma. He would have told you sooner but the paging system wasn’t yet in existence so . . . At this point do we have thoughts on who we’re talking about? It could be many things that led to his death. Given this incomplete but, thanks to my primary source, excellently summarized 2300+ year old case history, what do you each think is the most likely diagnosis? Alexander the Great Does Stuff The benefit to being a medical history podcast is to take license to be brief about the non medical history aspects of Alexander the Great’s life and conquests. They could be their own show if not a Netflix six part series, even. Born in 356 BCE to King Philip of Macedona (known to his friends as Phil the Thrill), Alexander would go on to do stuff and things with his relatively short life. He is Alexander the Great, after all, and not Alexander the Honorably Mentioned. Lots of those things were related to military prowess and having a mysterious death at a young age. Alexander had a formative childhood, hanging out with Aristotle and stuff, who taught him rhetoric, science, and philosophy at age 13. That’s a good start, methinks. Alexander’s relationship with King Phil, his father, had some ups and downs. Phil gets married again in 338 BCE (Alex is 18 at the time) and he and Alexander get into a drunken spat at the wedding banquet. This is where we trace the time-honored tradition of having messy family situations erupt at weddings. Instead of killing his son for being mouthy, King Phil exiles Alexander for six months, cools down, and they’re more or less good at that point. Things change quickly for Alexander when his father, unexpectedly, comes down with a case of being assassinated in 336 BCE, making Alexander the king of Macedonia at age 20. I’ll take a moment to point out where Macedonia is on a map, figuratively with my words, that is. Much of what was then Macedonia would be land of Greece extending into Bulgaria, Serbia/Kosovo and Albania. Therein is a country called North Macedonia which still exists today where we have a wildly devoted fanbase for this show (2 downloads ever). At the time Alexander takes over, Macedonia is in rough shape and everybody’s mad that he’s the king. There are revolts and stuff. It’s a bad start. Everyone knows that if you’re thrust into an unpopular position of leadership in the age when kings were killed for sport, the best thing you can do is establish dominance early. Alexander does this by crushing the revolt of Thebes in 335 BCE, silencing his critics and even receiving an apology from the Athenians. Total alpha bro move right there. (Pause to appreciate the multiple dimensions of this joke because alpha is ridiculous as a concept and Alexander is kinda Greek). The thing that Alexander the Great and I have in common is that we’re both fans of David Mamet’s Glengarry, Glen Ross. Alexander believed in the ABC’s–always be conquering. Coffee is for conquerors, except that he would have preferred alcohol at the time. They didn’t drink coffee in that part of the world at that time so far as I could find. He conquered all the things–at least all the things from Gibraltar to parts of modern-day India and much of the Mediterranean in between. One of his most famous beefs is with Persia which he invades in 334 BCE and basically takes city after city on his way to Egypt–then under Persian rule. He goes as far as to declare himself Pharaoh in 331, founded Alexandria and thereafter finds contentment in his achievements and retires young, surrounded by adoring subjects. No he doesn’t, obviously. He’s far too alpha to relax and has to keep conquering stuff so he heads east into India and it does not go as well as he might have liked. Apparently out of his 120,000 infantry and 15,000 cavalry one in four returned after his campaign. The most surprising fact to me is that he found that many battle ready people in a succinct geographic location in the 330’s BCE. That was probably a third of the world’s population at the time in his army, right? It may surprise you to know that those one in four surviving troops were less than enthusiastic about continuing on with Alexander’s lust for war. A bunch of nobles with ancient-sounding names start conspiring and denying that they’re conspiring when called out about it–like lol j/k, not trying to assassinate you, man–and plenty of people end up jailed, exiled, or unalived in his circle. Alexander decides that the best thing to do is start a new military campaign and maybe sail way out west to Gibraltar and maybe find something to conquer out that way. On his way he stops in Babylon in 323 BCE where stays at the palace of Nebuchadnezzar II (known as Nezzy to his friends) to hang out and drink and stuff. That brings us to our medical case, previously discussed where Alexander the great drinks a bunch and gets sick the next day with severe intermittent abdominal pain, followed by fevers and generalized weakness, dying 11 days after becoming ill. [Summarize their thoughts on what killed Alexander the Great] I’ll talk about some of the leading thoughts and possibilities on the death of Alexander the Great, and then I’ll give what is considered to be the most likely answer based on expert opinion Was it murder? As has been mentioned, being a ruler of the ancient world carried a higher risk of regicide compared to that of the regular population. It was mentioned in the case that Alexander’s fatal illness was preceded by a night of drinking. If you would have asked him how much he usually drank, he would probably say “two beers” or, rather, “two wines.” That may be true, but when you’re measuring the quantity in “bowls of” or “buckets of” it does give some perspective on the amount of alcohol he could put away. Was something in the wine he had the night before? It is a distinct possibility. Many poisons were well known to the ancient world–just ask Socrates. We’ve had more than one case on this show featuring heavy metal poisoning. I’m not talking Fleshgod Apocalypse heavy metal, but rather arsenic or lead as possible culprits. Lead is questioned given speculation that wine–often homemade–was stored in pottery that had lead in its glaze finish. It would, however, take a large dose of lead to cause acute intoxication and death, unlikely to happen in this manner. Chronic lead poisoning might be another issue. Arsenic would be worth considering. It was known to the Greek physicians of the time, including some dude named Hippocrates who liked to use it to treat ulcers. Name recognition aside, I think Hippocrates was bad at medicine (as were many of his contemporaries prior to the scientific method when medicine was just “making stuff up.”) Large quantities of arsenic can cause inflammation of the intestinal lining including hemorrhagic damage. It can cause liver necrosis as well–thinking of the right upper quadrant pain. People can develop shock and pulmonary edema due to capillary leaking with acute arsenic toxicity. A progressive neuropathy can develop causing weakness which could look like the picture described here. Arsenic is a realistic culprit. The fevers don’t quite fit, though. Alcohol Related? Alexander the Great loved his alcohol. From many accounts he would drink large quantities of wine. He even called for wine to “quench his thirst” when he was dying from this illness and fever. What’s not clear is to what degree alcohol contributed to his death. I actually came across articles that evaluated whether researchers thought Alexander qualified for the DSM -V criteria for alcohol dependence–spoiler alert, the answer was “no.” For all the quantity of drinking that he did, there was never any description of physical alcohol withdrawal symptoms such as tremor or hallucination. Given the limited information available to piece this together, that does seem to make it unlikely that he died from “Delirium Tremens,” the name for the most severe and deadly level of alcohol withdrawal. It is a very bad disease, make no mistake. I feel like he did have some evidence of a pathologic association with alcohol. Considering that Alexander killed one of his best friends, “Cleitus”, with a javelin to the chest following a drunken argument, I feel like that might suggest he had at least a problematic relationship with alcohol even if his body wasn’t dependent on it. Though he may not have drank every day, when he did have alcohol, he had a lot of it for days at a time and then may have taken breaks. It’s probably difficult to ride a horse into battle drunk so I’m guessing he may have been sober during the battles. Hard to say for sure. Pancreatitis was one of the first thoughts I had. Severe abdominal pain following a heavy night of drinking, then becoming severely ill in a time before we had modern treatments for this condition seems compelling. In alcohol induced pancreatitis, there is an association between drinking and inflammation of this important organ. The pancreas is in your abdomen, towards the back, in the area of the xyphoid process / solar plexus. It causes severe pain when it becomes inflammed–usually felt through to the back–and can vary from mild to super mega bad and deadly as a disease process. The pancreas is used in both digestion–making juices that break down food in the small intestine, as well as in your metabolic pathways (endocrine system via the bloodstream), i.e. making insulin to let your body use sugar. I was surprised to find–in refreshing myself on the basics of how pancreatitis works–that the mechanism as to how alcohol causes this organ to swell and start leaking digestive juices on itself is not well known, but alcohol is one of the two most likely causes for pancreatitis–especially here in the U.S. The other is gallstones. Pancreatitis can definitely be deadly. The pancreas can not only destroy itself, but, in doing so, can cascade the body’s inflammatory system. This could cause fevers, a sepsis-like syndrome, and lead to shock and death. There is also the possibility of hemorrhagic or necrotizing pancreatitis which are every bit as bad as they sound. The thing that doesn’t seem to fit pancreatitis is the way the abdominal pain was described. It comes on strong but then seems to subside before the fever and other issues start happening. Often, pancreatitis pain is very constant and awful. On the flip side, necrotizing and other severe acute pancreatitis can cause peritonitis–inflammation of the lining of the abdominal cavity. This in turn might give the fevers and ultimate demise of Alexander as we discussed. What about the generalized weakness–moving just eyes and minimal extremity movement? Pin in that. Fever and Infection? Alexander the Great had many days of fever following his initial abdominal pain. This reasonably raises the question of an infectious disease. Several have been questioned given the story we know. There are some who think it could have been West Nile Virus. This was a fun option I came across. The historian Plutarch described that when Alexander came to Babylon, a flock of ravens died. WNV has high mortality rates for birds–I’m sure we all know that–and it was identified as a virus in Israel in the year 2000. This suggests it may have been in the middle east and accompanying region for who knows how long. It is carried by mosquitoes and can give fevers, body aches, headache, rash, and convulsions and coma. It can also cause a weakness that could render someone unable to move. Although it’s technically possible, the severe, neurologic cases of WNV are rare (<1%). Abdominal pain isn’t a large feature, either. I’d put this into the neat mention but probably not category. I am not convinced by a pile of dead birds. There are a bazillion other infectious agents in the present and ancient world and we won’t visit them all, but I’ll pivot here to talk about the one that is believed to be the culprit. An Expert Opinion The summary of the case I’d used in the beginning was written by the infectious disease specialist named Dr. David Oldach. His paper on this subject was my primary source and, though I was favoring something along the lines of pancreatitis, his expert discussion on this case changed my inexpert opinion on the matter. We return to an old friend of the show, Typhoid. It’s caused by Salmonella infection, can lead to many of the things we see in Alexander the Great’s death. Abdominal pain and tenderness can certainly be present in many people who have Typhoid. According to even early research by Dr. William Osler (pause for effect), 60% of cases he observed complained of such things. Typhoid was all over the place back in the day. In addition to that, some wonder about Alexander’s lover with fever that was mentioned and as to whether this is where he might have caught a typhoid infection. Okay, abdominal pain isn’t enough by itself of course but one would expect it to be intermittent here. There is a complication that can happen with typhoid and that is intestinal perforation. The infection can lead to a breakdown in the lining of the intestine which would cause sudden pain was the perforation happens. Then, you can imagine the substance–including partially digested food and a bajillion bacteria–inside the intestine leaking outside of it. This causes fulminant infection in the peritoneum (abdominal lining) resulting in peritonitis and overwhelming infection. But what about the generalized weakness? I’ve been dancing around this a bit, but there is significant speculation that Alexander the Great may have developed something called Guillain Barre syndrome during the course of his illness. Guillan Barre syndrome is a neurologic complication resulting from many illnesses. It’s an auto-immune reaction whereby the immune system attacks various nerves in the body, causing a picture of ”ascending” weakness starting in the legs and then ascending up the body to eventually, if unchecked or severe, involve the nerves that control your diaphragm muscle and thereby your breathing. We do have the ability to recognize, diagnose, support, and treat someone with Guillain Barre syndrome. Alexander the Great had cool baths and alcohol which are less effective. Numerous articles suggest that Alexander may have languished in an unrecognized, paralyzed state for days as his breathing slowed and also that he may have been prematurely declared dead, though I’d argue that I doubt his survival chance was much above zero at that point. It’s still a bit of nightmare fuel that would be very unlikely to happen today–at least with modern diagnostics–so that should help. Summary: I think it’s reasonable that Alexander the Great had contracted Typhoid fever, leading to his severe upper abdominal pain signaling a perforation, and had a brief period of time until the peritonitis and overwhelming state of infection kicked in. He then has a complicating Guillian Barre syndrome resulting in paralysis until he dies. Dr. Max Doctor with a mustache. Case A 15-year old girl presents with onset of fatigue for two days; she has paresthesias of the left hand, and today developed double vision and felt unsteady, with nausea and vomiting. She’s otherwise healthy; a three-sport athlete, does well in school, no illicit substances. Initial differential? With above symptoms, she has a normal MRI. By the fourth day, she develops fever, slurred speech, nystagmus, weakness of the left leg, and tremors of the left arm. Change in approach? A month ago, there was an incident at a church; there was a bat loose in the church which ran into a stained glass window and was stunned. She went to help God’s creature, which bit her on the finger for her troubles as she released it. The area was cleansed and healed. She had no interval symptoms. Yes it’s rabies. What’s her prognosis? Main Story Clinical Presentation
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Dr. Aaron Silver Fox Doc The Case Imagine you’ve got a 50 year old male, we’ll call E.B., sitting in front of you in your medical history emergency room. He’s coming in because he’s having problems eating. His teeth are falling out and he’s having jaw pain. His vitals are fine. He has no facial swelling. He does have several loose teeth, however. He says it all started when he fell out of a bunk bed and hurt his arm 5 years ago. He may or may not have had x-rays or formal diagnosis–this is not clear. They were using x-rays for just about everything back then (early 20th century). He went to see his doctor who gave him a new medication which was supposed to stimulate his endocrine system. He loved the stuff. He drank a lot of it for years. Like, a lot. He gave it to his friends, his girlfriends, and even his racehorses. He thinks he’s had about 1,400 doses of the stuff. His arm got better and he felt great! Not only did he no longer have pain, but, just like his doctor said, it did improve his energy levels and libido. His girlfriends at the time started to call him, at the age of 47 if you can believe it, the “foxy grandpa”. Everything was great up until last year when the medication seemed to stop working. He was no longer getting that extra zip, as they say. And now, a year later, in 1931, his teeth are starting to fall out and, oh-by-the-way, he should mention his headaches and jaw pain and weight loss. He asks, “doc, do you think it has anything to do with stopping that medication?” (Radithor) The Medication What you’ll come to find out is that this man has been taking a very special medication. It’s not available by prescription, mind you, but he did get it from his doctor. And, importantly, his doctor, in turn got it from another “doctor”--more about the quotes later. You see, this story is taking place in the time before the FDA had the power to regulate what could legally be sold as a prescription medication. If you were an enterprising con artist, you could come up with a formulation and “patent” it as a medicine which allowed you not only to sell it directly to the public (or better yet through physicians), but you could do so without having to certify its safety profile or limit it by requiring prescription. Safety measures are, we can all agree, tedious. Our patient in this story is named Eben (short for Ebenezer) Byers and he has been taking a patent medication called “Radithor” for three years, nearly around the clock. If something is supposedly good for you, it’s best to take as much of it as possible without moderation or concern. What do you think might be special about Radithor? As you might have guessed, Radithor is radiation in a bottle. It is distilled water with a guaranteed 1 mCi (1 microCurie) amount of both radium 228 and 226 therein. The manufacturer is even willing to guarantee that you are getting irradiated because they had a thousand-dollar bounty out to anyone who could prove that there wasn’t radiation in each and every bottle. That’s standing by your brand, if your brand is being scientifically negligent, but to my knowledge in researching this, the bounty was never claimed so I guess that’s worth something? You could find printed advertisements or articles in and around 1928 about Radithor. In one example it was said the radium inside could “add fifteen years to anybody’s life.” An inventor that, at least as far as I could tell, had nothing to do with the making or selling of Radithor wrote that the “radio-active water makes old men feel young - peps em up. Tones up the system, reduces high blood pressure, and softens hardening arteries.” It should be said that a general rule in the world of medicine is that if something is said to treat many different conditions that have many different causes, it is more likely that said treatment does nothing at all. Except for my orgone chamber. That’s the only exception to the rule. Radithor was worse than that because not only did it not offer treatment for the things mentioned, it was intensely dangerous. But people didn’t quite appreciate that at the time because radium and radioactivity as medicine were in vogue. After the Curies discovered radium and its initial radioactive properties, using radiation as a medicinal therapy became very popular and there was no early fear or respect for the effects of radiation. We did an episode a long time ago on the “Radium Girls” which did touch on the hazardous ignorance of what radiation could do to the human body at the time. This was also a time when your local shoe store had x-ray boxes for making sure those shoes had a snug fit around your metatarsals. Radithor is another interesting example of this fascination with radiation but with a quack medicine angle. That’s a bad combination. The Quack One of the surprising things about the doctor that brought “Radithor” to the market is the fact that he wasn’t actually a doctor at all. He was a guy who went to Harvard for a bit and had to drop out. He didn’t even make it to medical school, but he did go to Harvard so, he was at the school that had a medical school, and, I guess, that’s close enough to doctor in the early 20th century. That man’s name was William J.A. Bailey. He had a bit of a rough start in life. He was born in Boston, MA in 1884 as one of 9 kids, raised by his mother in poverty as his father died when he was young. Somehow he does make it into Harvard and goes on to not finish as mentioned and apparently mounting debts got the best of him. Getting into and finishing medical school is hard. Saying you have a doctorate from the University of Vienna is much easier and probably harder to check up on in the age before Google, because we are, again, talking about the 1920’sl. I’m not sure of the details but, aside from using a fake “M.D.” after his name to sell Radithor and other sketchy meds later in his career, considering Bailey did plead guilty to the illegal practice of medicine in 1927, I suspect he was doing some real sketchy impersonation of a doctor-stuff in some manner. And “not-a-doctor” Doctor Bailey had a history of being sketchy. He was nothing if not entrepreneurial. Prior to making and selling Radithor, Bailey had a host of unseemly start up business ventures. My favorite was the Carnegie Engineering Corp which was promising a newly designed automobile–I don’t know the exact year but imagining it’s Ford Model T times–for the low low price of $600. That was probably 4.2 million in today’s dollars. All you had to do is send Bailey your $50 deposit and you and all the others would definitely get that car, eventually when he got around to it. If you happened to go to see the car manufacturing facility, the good news is that there was one. The bad news was that it was an abandoned sawmill owned by Bailey that had a single box of tools therein. I’m not sure if he owned the tools but, given most of his history, I’m sure he stole them from an orphan or something. He paid a fine and did 30 days hard time in prison for this venture. He was ultimately undeterred and, I believe, this is the worst consequence he may have ever faced, spoiler alert. As mentioned, radiation and radium were all the craze at the time. So Bailey thought he’d get in on it and there’s a fun call back to an earlier episode here. In 1922, he founded the Associated Radium Chemists company, and while he was workshopping a way to turn a profit with some sort of medicinal radioactive formulation, he happens to get in touch with a guy named Dr. John R. Brinkley (aka Dr. Goat Balls) and they try to come up with some sort of mashup project–a bullshit Voltron of radioactivty and goat testicles of some sort. Sadly it did not work out and Dr. Brinkley would go on his own quack path to convince people to have him surgically put goat testicles into their bodies for “reasons”. Seriously, we did an episode on it if you’re curious. By the 1930’s Bailey had three different companies selling radioactive products to the public but, by far, the most successful was Bailey Radium Laboratories out of East Orange, N.J. It made Radithor and sold it at a crazy profit. Bailey’s company was believed to have sold 400,000 bottles at $1 each (roughly 6.9 million dollars in today’s money, actually) at a %400 profit margin. Not bad for a literal poison being sold legally on the market. Let’s return to our patient and find out how this all happened. As I said before, the unfortunate patient in our opening story was one, Eben Byers. Things will not go well for him. Born to a wealthy family in 1880, Eben was an Ayn Rand fantasy come to life. He was a wealthy industrialist who became president of his father’s company, the Girard Iron Company, probably based on his own talents and had nothing to do with his family ties. He was therefore incredibly wealthy. He was an avid sportsman–especially golf. Apparently he won the national amateur golf championship in 1906, back when golf clubs each weighed 30 pounds and were without carbon fiber and probably had sandpaper instead of grip tape, so that is an impressive feat. He was a Yale graduate and a fateful trip back to his alma mater for a sporting event would change everything for him. Eben Byers was riding a train back from the 1927 Harvard - Yale football game, as you did in 1927. He was in a sleeping berth (i.e. train car bunk bed) and when the train lurched, he was thrown to the ground. This was before the invention of seatbelts or safety measures at all, I think. If you don’t believe me, look at the football equipment and death and disfigurement rate of that sport at the time. Seriously. He hurt his arm when he fell and it wasn’t getting better. I didn’t see any documentation of a broken bone, but his arm seemed to be an issue for a while. He goes to see his doctor for treatment and relief of the pain. His doctor is a guy named C.C. Moyar in Pittsburgh. Moyar gave Byers Radithor. Since this wasn’t a prescribed medication in the traditional sense, Moyar, and other docs of the time, would suggest it and other patent medicines to their patients who would buy the stuff from the doctor. Interestingly enough, William J.A. Bailey would offer Moyer a ~16% kickback each bottle sold to their patients. There were many other docs doing this. Certainly no opportunity for corruption could exist there and I’m sure the Radithor recommendations were quite objective. This goes on for about three years and an estimated 1,400 doses of Radithor are consumed by Eben Byers. While he seems to think it’s helping–I mean, his arm does incidentally get better at some point–he is killing himself slowly with doses of radiation. Well, I guess it’s open to interpretation that Bailey and Byer’s doctor are also killing him in a sense. It’s all bad stuff. The story I made up of him coming to the ER at the beginning of this episode refers to the time Byers started to have his teeth start fall out in 1931. He had stopped the Radithor a year prior as it didn’t seem to be giving him the same zip in his step or moxie or whatever it was supposed to do. It was, however, filling his skeleton with radium and its accompanying radioactivity. Byers worsens. His jaw pain worsens as he suffers from osteonecrosis–death of bone–from the accumulating radium. This similarly affected the Radium Girls as you might recall. He’s losing weight, developing worsening headaches, and eventually drastic measures have to be taken as more and more of his skull about the mandible and upper jaw are rotting away with radiation. I’m not exaggerating there. Byers ultimately undergoes multiple surgeries to remove these necrotic bits of bone including his entire mandible and almost all of his maxillary (upper) jaw. The surrounding soft tissues are horrendously damaged in this area. He is only left with two of his upper teeth and literally nothing else of his lower face. I will say, there are pictures of this aftermath available on the internet, but I would suggest that they are extremely graphic even for a seasoned ER physician. It’s okay not to Google things you can’t unsee. As this disfigurement is happening, the winds of bureaucratic change are mounting against people like JA Bailey and their patent medications–albeit, slowly as you might expect. Way before this whole episode there was plenty of mounting concern over “patent medications” such as Radithor and any number of other non-radioactive snake oils. In 1906, the Pure Food and Drug act was passed which went on to help with the rise of the FDA, spelling a beginning to the end of the patent medicine era. It won’t be until 1938 that products marketed as medications would have to be shown to be safe and effective through research. We did get many products such as VicksVaporub and Milk of Magnesia, still used today, out of the patent medicine era–though their claims as to what they could do medically speaking have been heavily edited since the 1930’s. But all of this doesn’t help Eben Byers as we’ll see. In this brewing atmosphere of patent medicine skepticism, the FTC formed a case against Bailey and, as part of their investigation, they sent a reporter to interview Byers at his oceanfront mansion in Southampton, Long Island. That guy’s report read: “his whole upper jaw, excepting two front teeth, and most of his lower jaw had been removed. All the remaining bone tissue of his body was slowly disintegrating, and holes were actually forming in his skull”, “a more gruesome experience in a more gorgeous setting would be hard to imagine.” Not long after, Byers died of cancer at age 51. What kind isn’t clear. The estimated level of radiation due to radium ingestion was 3x the lethal limit. His bones were calculated to have 36 micrograms of radium deposited throughout them. 10 micrograms would be at the fatal level of such things, for reference. He had to be buried in a lead lined coffin and when he was exhumed in 1965 for study, his remains were still very much radioactive. Byers’ death did help popularize the crusade against patent medications and people like Bailey. Speaking of self-described doctor Bailey, he was ultimately forced to admit that Radithor had no therapeutic value and could not say it was harmless thanks to an FTC order filed in 1931. He did no jail time for any of this because it was the 1930’s I guess? Seems crazy to me. Bailey said he was not put out of business by the FTC but rather blamed the Great Depression. Lest you worry about Mr. Bailey’s post script, I’ll have you know that the radiation did get to him as well. He died in 1949 of bladder cancer, aged 64. He was a wealthy man thanks to Radithor and, 20 years after his death, he too was exhumed and found to be “ravaged by radiation” all that time later. So, I guess that’s all fitting in with a morally ambivalent cold universe in some way? I don’t know, it’s just how it works sometimes. There you have the story of Eben Byers and the patent medicine, Radithor. Sources: https://content.time.com/time/subscriber/article/0,33009,743525,00.html https://en.wikipedia.org/wiki/William_J._A._Bailey https://en.wikipedia.org/wiki/Eben_Byers https://orau.org/health-physics-museum/collection/radioactive-quack-cures/pills-potions-and-other-miscellany/radithor.html** https://web.archive.org/web/20160113201140/http://www.alleghenycemetery.com/images/newsletter/newsletter_XIII_1.pdf http://large.stanford.edu/courses/2016/ph241/yoon2/ https://sc.edu/about/offices_and_divisions/research/news_and_pubs/caravel/archive/2020_fall/2020_medicalknowledge.php Dr. Max Doctor with a mustache. Case: Ok, so, we have a 38 year old man who presents with his sister-in-law, who’s taking matters into her own hands because this guy, we’ll call him Yury, he’s just working all the time and ignoring the fact that he’s declining. He’s moody. He doesn’t want to tell you much. Does this ever happen? His significant other does most of the talking. For a few months now, he’s had severe headaches on an intermittent basis. He’s been smelling strange things; on a train platform in Detroit he smelled burning garbage, which, for Detroit, probably isn’t that surprising, but no one else smells it. He’s intermittently smelled burning rubber as well when no one else does. This was all sort of ignored for a while, but during a recent performance–he’s an excellent piano player–he had some significant trouble playing, and even seemed to black out a bit during the performance. His appetite’s been down, and she’s noticed that he’s having weird mood swings and acting erratically. He seems to be withdrawing, and seems very flat at times. Exam: normal. Thoughts? Well, to give us a bit of a clue, despite what you just said you’d want to do, it’s 1937, so there was no more testing at this time, and he went home. You are working a week or two later when he’s brought back to the hospital after sudden neurological changes and unresponsiveness while on the toilet. On exam now, he’s got what’s described as right facial paresis, reported miosis (??), decreased responsiveness, papilledema, and retinal hemorrhage. At first he has increased reflexes, then decreased reflexes, and then develops a Babinski sign! Ah! Let’s go through these terms. Babinski indicates upper motor neuron damage. Why haven’t I done this since medical school? Stanford Medical school says the Babinksi sign is proof that doctors can make confident decisions with just a thorough physical exam! Since it’s 1937, they did a lumbar puncture. Thoughts? Given the limited information above, would you do this? Well, they did, and the opening pressure was 400 mmH20. Jesus Christ. Normal is a range from 6 to 25. Soon after he slipped into a coma. Guesses on his vital signs and subsequent mental status? Let’s discuss the PTSD we all have from the Neuro ICU. To back up a bit, assuming we see the problem on CT scan, what sorts of things would we do these days? Well, to their credit, although I don’t see the actual records online, they did try to get a Neurosurgeon! This case happened in Los Angeles; the sister-in-law called her friend, Emil, who called his friend Harvey the fancy Neurosurgeon in Boston, but Harvey was retired. Harvey recommended his protegee Walter, but said Walter was fishing in the Chesapeake Bay with Harry, the Governor of Maryland. Emil called the White House, and I like to imagine that FDR himself called the Coast Guard to pull Walter off the boat and fly him to LA. This is beyond the typical 30 minute response for emergent surgical staff on call. Even with Walter on the way, doctors at the actual hospital where Yury was operated and removed a large brain tumor, thought to be a glioblastoma; despite this, Yury died. The leading theory is that this patient had herniation and Duret Hemorrhages, or bleeding in the brainstem, from the herniation. Regardless, this is devastating and, frankly, not survivable. Herniation? What’s it mean? How does it apply to the ED? Duret hemorrhages were described by Henri Duret, an old, apparently racist Frenchman who didn’t do a lot of surgery himself but did a lot of anatomy work and recognized the importance of the smaller blood vessels that come off of what’s called the Circle of Willis and feed the brainstem as well as multiple key parts at the base of the brain. Discuss how bleeding in the brainstem or the base of the brain can range from silent to completely devastating. He recognized, in 1878, what we now refer to as diffuse axonal injury; when you have a severe traumatic brain injury, the shear forces at the base of the brain lead to multiple areas of small hemorrhage that make the injury much more devastating than it would otherwise be. He totally got this right, given how we now know about how the brain sort of torques at the base. Discussion This is the story of George Gershwin, one of America’s most famous musicians. Gershwin was born poor to Russian Jewish immigrants in 1898, after his family fled Russia due to prejudice and threatened military service. Thankfully they completely escaped anti-semitism in the US. He left school at 15 to earn a living writing songs after multiple members of his family, George included, demonstrated significant talents for composing, song writing, and musicianship. He and his brother Ira managed to write multiple musicals, and he’s known for Porgy and Bess as a musical, and Rhapsody in Blue, which combines both Jazz and Classical music and was a big hit at the time. He was 38 when he died, and was writing musicals and new songs the whole time. Jazz standards that Gershwin wrote include ‘Embraceable You’ and ‘I Got Rhythm’, along with his brother Ira. In this story, it’s Ira’s wife that tried to help him when he got sick, and Yury is a Russian nickname used for the Russian version of George. He died 10 years too late to be included in the 27 club, but still way too young. References
Dr. Aaron Silver Fox Doc Part 1: The Dutch and English Societies, origins
Part 2: Ventilation Continues
Part 3: Compressions
Part 4: Defibrillation
Part 5: Present Day and Popular Culture
Precordial Thump digression
Outline and Notes Holding
References
Dr. Aaron Silver Fox Doc This episode isn’t just an excuse for me to talk about some wrestling history–it is definitely that though. It’s also to talk about a unique medical condition in how it affected a special person in the world of wrestling. We’ll start by talking about Andre The Giant, one wrestler that many non-fans of the sport have probably heard of, and then we’ll pivot to talking about the medical condition that made him so famous. I promise I won’t go too far into the wrestling side of this story so Mike doesn’t leave, but we have to talk about a bit of it because it’s awesome. Andre Rene’ Roussimoff grew to be every bit the giant of his namesake, both in physical stature and his career in the world of professional wrestling, which some might argue is the pinnacle of performance art and human achievement. I would argue that it is. After his initial training as a wrestler in France where, again he was an 18 year old, 7+ foot teenager who could just lift cars, mind you, he eventually made his way over to the U.S. where he wrestled in various regional wrestling territories as a true spectacle. He would come to town, beat everyone while crowds stood in awe of his size and ability to pick up and throw his opponents whether or not they wanted him to. Then he’d move on to the next town and the next wrestling territory. It was important not to keep him in town forever since nobody who saw him would ever believe he would lose a match. That’s also why he rarely if ever won championship belts. In 1973, he captured the attention of Vince McMahon Sr. who brought him into what was known as the WWF at that time. Note this was the father of the Vince McMahon who presently oversees the WWE and is known to not only be a ruthless businessman, but also to be a person who should not have a mustache–gotta be aware of recent wrestling to appreciate that one, but I know someone out there will. It makes him look every bit as unsettling as his history in the wrestling business would suggest he is. During his career, Andre was billed as being 7’4” and up to 555lbs. It may shock you to know that there may be some exaggeration in wrestling when it comes to these things, but it’s probably only a little bit over the mark for Andre’s true size. He was called the 8th Wonder of the World and indeed did wrestle all over the world. His biggest match, perhaps, was at Wrestlemania III in 1987, when I was all of 5 years old, Walk Like an Egyptian by the Bangles was #1 on the Billboard charts, and Aaron and Mike were celebrating their graduation from medical school, to give everyone historical context. Andre allowed Hulk Hogan to bodyslam him and was pinned in front of 78,000 fans–arguably the pinnacle moment for 1980’s wrestling. I did say he “allowed” Hogan to do so because, given his size, if Andre didn’t want to lose, he wouldn’t. I encourage everyone to check out the excellent HBO documentary on Andre the Giant to hear anecdotes about the times Andre didn’t like the wrestlers he was pitted against and used his size to make their time in the ring together difficult. And lastly, if you didn’t know him for the wrestling, you probably saw him in several movies. He was the star of the 1987 hit, The Princess Bride, where he played Fezzik who was, also a giant. I don’t know who else was in that movie because it had Andre the Giant in it and that’s by far the coolest thing about the movie. At this point, I hate to turn away from talking about wrestling, but there is a medical history part of all of this. Now that we know a bit about the man’s wrestling career, let’s talk about the underlying condition that made him 7+ feet tall, aptly named gigantism, and how it was discovered. I’ll note here that this condition may be referred to as acromegaly and I’ll be sure to tell you the difference between the two after we get to what causes them. For now I’ll use them interchangeably, but there is a difference. The first time a physician described gigantism was in the 16th century. It wasn’t the first case ever, of course, just the first time a physician took the time to write a scientific–if not rude and unkind–account of a patient having it. There is little to no tact in historic medical writings. Johannes Wier (pronunciation?) was a Dutch physician who in 1567 wrote about what he dubbed a “female giant.” She was 25 years old and had been making a living as a traveling sideshow performer to support her parents. Her stature was the show. She had apparently been normal in appearance until her early teens when her height, facial, and extremity size had all increased markedly. I mentioned his description was unkind and include it as an example of how harsh earlier medical journal observations could be, “her form was not attractive, her temperament was simple and stupid, and her whole body was sluggish.” If I could say anything redeeming about Dr. Weir’s writing, it’s that he would go on to write a bunch of treatises on why burning women for witchcraft was dumb and cruel and he apparently may have been among the first to use the term “mentally-ill” to describe women accused of witchcraft as opposed to saying they were, you know, “a witch.” So I guess that’s kind of progressive for the 16th century, maybe? Many cases of similar patients with similar findings–large extremities (especially hands, feet, heads/faces and tall stature) would be described over the subsequent centuries–interestingly enough often in France and the UK and Ireland it so happens. The first time the term “acromegaly” was used to describe this was in 1886 by French neurologist, Pierre Marie. Pierre was covering for his buddy, a physician named Jean-Martin Charcot who was a big fan of things that come in threes. Pierre Marie was seeing a few of his Charcot’s patients in late 19th century Paris–not clear if they were referred to him or he was, like, taking call for the clinic or something. One woman, aged 24, stopped in after her relatives noted a significant change in her appearance. Not sure why or what she was doing, but she was away from her family for a few years and when she’d returned many of them could not recognize her, due to the change in her appearance. Her face had grown, her arms, legs, and hands were quite large, and she, to Dr. Pierre Marie’s surprise, did not resemble old photos of herself. He dubbed the condition “acromegaly” which refers to extremities (akron - tip) and large (megas). Incidentally, she was having some difficulties with her vision which is a clue to what causes this condition. Let’s go there next. Ever since Dr. Wier’s initial description, on through the centuries leading up to Dr. Marie’s coining of the term, many physicians were aware of patients with enormous extremities and general size, and some of them were finding a curious association when they decided to open them up–post mortem, of course. We’ll start with a missed opportunity to make an eponym. A historically famous Scottish surgeon of the 18th century, John Hunter, came close to being the first to find a clue. He’s like the Drew MacIntyre of the world of surgical history, just for reference. He had procured the body of a man named Charles Byrne (aka Patrick O’Brien–I did not dive into why he had such different names) who was 7’7” and therefore known as “The Irish Giant”. Hunter loved collecting specimens like other people collect baseball cards or pokemon. He was able to keep Byrne’s enormous skeleton for his collection but he never opened it up. My wife would not have that problem since, whenever she gets a new wrestling action figure as a present, opens the package and immediately nosedives its value. Fast forward to an Italian neuropsychologist named Andrea Verga who did open up his patient up during his career in the 19th century. He was working at an Italian hospital in the 1860’s when he noted a woman (I think she was a patient) who had what he called “prosopo-ectasia” or big face. He was also not kind in describing her features as you might imagine. She died a few years later in 1862 of infectious illness and he did an autopsy–I don’t know that she was a longer term patient of his or if you could call a weird sort of dibs on patients bodies or however he was able to do this–but he found a “walnut sized” tumor in the region of her pituitary gland. Notably, he did not find a normal pituitary gland. That patient was also having vision difficulties when she was alive because, anatomically, the pituitary gland sits near near a big ol’ crossing of vision nerves called the optic chiasm, which carry signals from your eyes to the brain. Tumors of the pituitary can grow to push on the chiasm and cause vision changes. Many, many autopsies on patients with acromegaly or gigantism were performed, all of which seemed to have abnormal growths on the pituitary gland. In fact, one Lithuanian endocrinologist-diabetologist (redundant specialty name) named Oskar Minkowski noted in 1887–the year after Acromegaly was named–that all patients with the condition had these pituitary tumors on autopsy. That same year, an Italian physician named Vicenzo Brigidi did an autopsy of the brain of the Italian actor Ghirlenzoni (single name, like Cher?). He had acromegaly. Birgidi put was the first to look at the tissue under a microscope. Subsequent physicians found further evidence, microscopically, that the cells of the pituitary seemed to be really, really active. At this point the physicians of the late 19th century were pretty sure the pituitary tumors were causing acromegaly/gigantism. They were right. Here’s what’s happening with this condition. In 95% of cases, a non-cancerous tumor grows in the part of the pituitary gland that makes something called “growth hormone.” It’s nice when medicine names things for what they do. Growth hormone causes many tissues of the body, especially muscles and bones to grow, including those of the face and extremities. When you hear about athletes taking HGH (especially if they’re going up in hat sizes as the skull thickens), they’re injecting a synthetic form of this hormone to grow muscles. There are many other effects of GH but that’s beyond the scope of this show. So this is where the difference between gigantism and acromegaly comes into play. They are both due to excess production of growth hormone from the pituitary tumor. The difference is WHEN that production starts. If it starts before puberty–i.e. before most of the bones are done growing in length, then you have gigantism, which not only includes enormous growth of arms, legs, feet, and face, but significant height increase since the bones can grow longer as well. In acromegaly, the growth hormone excess starts AFTER puberty, when bones no longer grow in length, but can, with extra growth hormone, grow thick and distorted. Both conditions can affect the shape of the face in slightly different ways because of this. Also important to know that soft tissues like the tongue or soft tissues (the meat, if you will) of the extremities will grow as well. Acromegaly and Gigantism are fortunately treatable, to a degree. If recognized early, the first line is surgical removal of the tumor which stops the extra growth hormone from causing the changes. The earlier you catch it, the less the changes become permanent. Surgical treatment was an early recommendation after they figured out the pituitary tumor was the problem. In 1908, Austrian surgeon Julius Von Hochenegg performed the first trans-sphenoidal approach for treatment of acromegaly, earning a headline in the NY Times that year of “ACROMEGALY CURED.” Well, it wasn’t far off but it wasn’t until surgical microscopes became all the rage in mid 20th century that this surgery was refined and more often successful. There are now some medications that can be used if surgery is not an option or to temper the condition if surgery is not completely successful. Let’s finish out this story with the end of Andre’s life. Andre likely knew as early as the 1970’s that he’d had gigantism. According to one of his close friends, he had said that, on his initial wrestling trip to Japan–where he was an incredible wrestling star–he was told by a physician there that he likely had a pituitary tumor. It was not confirmed and there is speculation as to why he did not seek out surgery at that time. It might have been that there was a language barrier between Andre’s lack of French interpreter while in Japan, or that he may have known the option was there and decided against it. His friend said Andre was told he could have surgery while in Japan but that he said “God made him that way and he wasn’t going to change that.” In 1981, orthopedist, Dr. Harris Yett, diagnosed Andre with a broken ankle and being a giant human being. Prior to having the Giant undergo surgery and what I can only assume is an enormous dose of anesthesia, Yett had confirmatory testing done to, well, confirm, that Andre did have gigantism. Surgery on his pituitary was discussed but Andre declined because “he thought it would interfere with his career as a wrestler.” The sad thing, among many, is that if Andre had the surgery in 1981, he would have likely lived a longer life. His skeletal structure would not have changed, per se, but it’s likely the excess soft tissues may have shrunk and that he could have continued his wrestling career longer than he was able to. Andre really, really loved wrestling and what it gave to him and it seemed as if he accepted the fact that he would die young, but would live the life of a star in the meantime. If that trade off seems difficult to accept, consider how hard life was for Andre–and indeed others who have conditions of acromegaly and gigantism. He was comfortable being a Wonder of the World in the wrestling ring, but outside of it, he just wanted a normal life. He couldn’t use a bathroom on flights overseas. Clothing and furniture had to be custom made. People always tried to exploit him for his size and he knew that. So maybe that’s why he decided to forgo a treatment that would still, essentially leave him the way he was? By the late 1980’s, Andre’s career and health were on a precipitous decline. He had mounting back issues and could barely walk. His weight continued to grow as did the size of his heart. Andre died at age 46 of a suspected heart attack complicating congestive heart failure, on Jan 28th, 1993. He was alone in a Paris hotel room where he was traveling to attend his father’s funeral as sad as that is. You might imagine that Andre the Giant was not the only wrestler to have gigantism. Many before him did. One notable example is still wrestling today, albeit on a limited basis. Formerly known as “The Big Show” in WWE and “The Giant” in WCW before that, Paul Wight was diagnosed with his pituitary tumor in his late teens. He had it surgically removed and remained 7ft tall and between 383-500lbs at various points in his wrestling career. He’s 51 years old and active in wrestling to this day. I hope he’s a fan of this show! Hi Mr. Wight! Sources: https://karger.com/nen/article/103/1/7/220198/The-History-of-Acromegaly*** https://www.ncbi.nlm.nih.gov/books/NBK538261/ https://www.wwe.com/superstars/andrethegiant https://books.google.com/books?id=tYPCDwAAQBAJ&pg=PT78#v=onepage&q&f=false (suggestion that Andre may have been told of diagnosis in Japan in 1970’s) https://en.wikipedia.org/wiki/WrestleMania_III https://www.hbo.com/movies/andre-the-giant https://www.wrestlinginc.com/1097011/andre-the-giant-and-robin-wrights-relationship-on-the-princess-bride-explained/ https://biographics.org/andre-the-giant-biography-larger-than-life/ Dr. Max Doctor with a mustache. This case takes us to the mid 18th century to jolly ol’ England where a nervous 37 year old male awaits in the examination room to discuss what he feels is something of an embarrassing problem given the sensibilities of the time. He’s unkempt and filthy. He tells the surgeon that he’s noted a lesion on his “privvies” that started as a small bump or wart, perhaps, but now has grown into a 50-pence sized ulceration on the bottom of his scrotum, also medically known as the yambag. Anything you’d like to know about him at this point? The exam is concerning. There is an ulceration extending from the lower yambag with raised edges. No purulence, no infectious smell, mind you. You can’t see into the scrotum but the top tissue layers and underlying fascia seem to be visible. What would you want to do in modern times for this–let’s say in the ER. What about in the 1750’s? The surgeon treating this man will become known for associating this particular disease with the man’s profession. I’d wager that anyone having completed a stint in contemporary medical school will be aware of this surgeon’s name because it’s pasted all over the medical textbooks. This guy collects eponyms like I collect wrestling posters on my walls–fun fact, I have more wrestling pics on the walls of my office than degrees, I realized. Here’s the thing about this case. I didn’t write it quite accurately. The 37 year old patient I’ve made up is fictional. Though he is the average age of diagnosis of this condition at the time, the sad truth is it would be more likely that the patient we’re talking about with this life threatening disease would have been more likely to be a young boy, between the ages of 8 and young teens, likely. He’s filthy because it’s his job to be and that job is very likely to shorten his life, if not by this disease, then by another occupational or health-related hazard. Do you know what we’re talking about today? This is the story of the Chimney Sweep’s Carcinoma, diagnosed by the famous English surgeon, Dr. Percival Pott. This is a tale of occupational medicine at its earliest stages. The association of this cancer with the job of cleaning out chimneys was not accidental. The discovery of this led to sweeping (pun!) changes in social expectations for children and the labor market. Before we get to ol’ Percival Pott himself, let’s talk about what this patient–along with way too many children–would be diagnosed with. Chimney sweep’s carcinoma is really squamous cell carcinoma of the skin of the scrotum. Squamous cell carcinoma is a cancer that arises from the cells of the same name which can be found in your skin or the linings of one’s hollow organs, respiratory and digestive tube structures especially. As with any cancer, the basic problem is that a cell undergoes some sort of genetic change or damage and begins to grow and replicate without stopping. This results in a tumor or growth in many cases, but, with Squamous Cell carcinoma, the initial findings can appear to be an ulcer or wound which does not heal and slowly grows and expands, destroying more tissue around it. This type of cancer is nowadays rare in the “privies” so-to-speak, but very commonly found on skin. This disease would start insidiously for the unfortunate chimney sweeps, often as a mildly irritated sore or pimple-like bump. Might get some bleeding from scratching at it. It would start on the scrotum and, if not treated, the cancer would spread to the other areas of the genitals and, as it destroyed more tissue from the scrotum, would work its way into the testicle and on into the lymph nodes and structures inside the abdomen. Even in the modern era, from what I found, if you can resect–surgically remove–the cancer before it gets into the lymph nodes of the groin, chances are much better. We do chemo and radiation for this as well nowadays. If it makes its way into the inguinal nodes–those in the crease of your hip–there is a 25% 5 year survival rate. If it makes its way into the iliac nodes (deep within the pelvis) there is no survival reported beyond that time. That’s grim. But why were children in Dr. Pott’s heyday being diagnosed with this awful condition so often? Well, it was the beginning of the industrial revolution so that means progress in so many ways–except for those that involve treating children like human beings. You see, from the ages of 4 to prepuberty, the problem was that young boys were just too good at fitting in super dangerous small chimneys where they could do the insanely unsafe job of sweeping a flue for the betterment of society from the 1700’s to the 1800’s. Let’s talk about chimneys. A housing tax in 17th century England had limited the number of fireplaces allowed per house. This meant that houses and buildings were built with a labyrinth of chimneys and flues to get the smoke and soot from one’s fire up and out the top of everyone’s houses to create that soupy fog of carcinogens a person associates with images of London and most other metropolitan centers of the time. Seriously, smog was like a permanent season according to some accounts. Chimneys can collect soot and soot can be flammable if it builds up. Worse yet, if a chimney was plugged, one can imagine how bad that would be inside the house. This meant somehow, someone had to crawl up into the chimney to clean out the soot. That someone had to fit into places as narrow as 9”x9” in some flues so the natural conclusion was to “hire” young boys (again ages 5-11) to strip naked and shimmy their way into the twists and turns of the chimney. You might think the aristocracy of the day gladly offered up one or two of their extraneous progeny for the job, but you might be astonished to hear it was not their kids doing this work. Nope, it was often orphans, street kids, or children from poor families. They were paid badly and took so many risks. Boys might get caught in narrowed spaces and many died of suffocation. Sometimes, the chimneys were still hot or literally on fire from the prior uses. The soot would irritate their eyes to the point that some kids went blind from constant rubbing and scarring of the corneas. The soot also contributed to lung disease. The best case scenario for these kids was surviving to become a master chimney sweep, but that meant making money by exploiting the next generation of unfortunate souls. It was very unlikely for a chimney sweep to live to adulthood, let alone old age. When children would die on the job, the coroners of the time would classify these deaths as “accidental” as opposed to “occupational murder” which is what I’d call it. Speaking of soot–it’s bad. I mentioned the chimney sweep children were naked. This is because it made it easier to squeeze through the nooks and crannies of the passages but, believe it or not, this was part of the problem related to the cancer we are discussing. Soot would cover their bodies and especially collect in the area of the scrotum. Soot contains numerous carcinogenic substances and, with its prolonged contact with the skin, accompanied by the accepted unhygienic conditions of being a poor person in this time in the streets of London, there was high risk of developing cancer of the skin of the scrotum. Let’s return to our friend, the whimsically named Dr. Percival Pott, who lived between 1714 and 1788. He’s an English surgeon, credited with being the first to associate cancer with an occupation related environmental substance. He’s considered to be an occupational health pioneer. Dr. Pott did his surgical apprenticeship at St. Bartholomew’s Hospital over 7 years for a cost of 210 pounds (for all of it). In today’s money that is about $75k USD. He finished that apprenticeship and was hired by the Barbers’ Company, then being licensed to practice surgery. If it seems weird that barbers are licensing surgeons, I’ll refer you to our prior episode #40 to learn more about that whole matter. In 1744 he became an assistant surgeon at St. Bart’s and he went on to be a full fledged surgeon there from 1749 - 1787, the year before his death. I’m pretty sure his career at that one hospital was longer than the average lifespan of a chimney sweep, I’m sad to say. Interestingly, Dr. Pott was not quite the stereotypical surgeon one might expect of this time. He was known as a conservative-minded surgeon who was not quick to rush into a procedure. He was not a fan of “heroic medicine” which can generally refer to the gung-ho, “do something” attitude of the time. Bleed the patient, put leeches on them, make them vomit out the bad bile and amputate, amputate, amputate the problems away! Not for Dr. Pott. Here’s an illustrative example. In 1756, well into his surgical career, Pott was thrown from his horse, landing into the muck of the street, sustaining an open fracture to his tibia. That’s the type of break in the bone where the bone bits peek-a-boo through the skin to see what the outside world is all about. That’s a bad thing because the muck of the streets at this time was chock full of mud and horse manure rich with bacteria which, I should add, Dr. Pott and his colleagues of the time, didn’t even know caused disease. Bacteria and bones don’t mix particularly well and open fractures–especially in the age well before antibiotics, were frequently fatal infections waiting to happen. Pott was able to pay one of his servants to go to a nearby jobsite and buy a door. The door was used as a stretcher to return Dr. Pott home to await the opinions of his surgical colleagues of the time. To nobody’s surprise they voted to amputate his leg, and Dr. Pott was probably all like, “that sounds super fun but I’d rather not,” and he opted to conservatively treat the wound and fracture. This means they cleaned the hell out of it, splinted it, and, in time, Pott avoided dying of both 18th century surgery and infection, going on to a full recovery. So it wasn’t without reservation that he suggested surgery for patients and would be sure it was the only chance. In cases of scrotal cancer, the chimney sweep disease, he was right. If the cancer could be resected before it went to lymph nodes, patients would do well enough. If not, these poor souls would have an untimely end. Pott describes the circumstances of the Chimney Sweepers Carcinoma in, dare I say, empathetic terms especially given the time:: “The fate of these people seems peculiarly hard … they are treated with great brutality … they are thrust up narrow and sometimes hot chimneys [sic], where they are bruised, burned and almost suffocated; and when they get to puberty they become … liable to a most noisome, painful and fatal disease.” That’s downright touchy-feely language given the time. Pott did care about these patients more than most. The association between this cancer, soot, and the awful life of a young chimney sweep did eventually lead to changes, albeit way slower than you’d like to imagine. Pott’s work was foundational in changing the social consideration for this job. It took an absurd amount of legislative baby steps to finally stop legally stuffing orphans into chimneys. The first was the Chimney Sweepers Act in 1788 (the year Pott died) which aimed to “protect” child workers. It did this by ensuring the minimum working age was raised to a far more respectable eight years old. In 1803, societies were formed to bring awareness to this problem. Succinct names for things had not been invented yet, so the English of the time came up with the following organization: The Society for Superseding the Necessity of Climbing Boys by Encouraging a New Method of Sweeping Chimeys and for Improving the Condition of Children and Others Employed by Chimney Sweepers. (which could go by the unpronounceable acronym, the SSNCBENMSCICCOECS). Acronyms were probably new then, too? In 1834, British parliament passed the “Act for the Better Regulation of Chimney Sweepers and their Apprentices” as well as the “Act for Safer Construction of Chimneys and Flues”. This raised the minimum working age to a double digit, ten years old! In 1840, legislators were all like, “FINE” and raised the working age to 16 years old with the kind recommendation that nobody under 21 should work in the chimney sweeping industry. As almost rational as this sounds, apparently nobody bothered to enforce all of these laws to this point. A commission at this time actually found that all of these bills and acts and whatnot somehow contributed to an INCREASE in child labor so that wasn’t good. Finally in 1875, almost 100 years post Pott’s death, an Act of Parliament forbade children of any sort of working in the chimney sweeping industry. What do you know? The rates of scrotal carcinoma dropped off precipitously. In the 1940’s, St. Bart’s, Pott’s old hospital, reported one single case in 5000 new cancers diagnosed. It turns out that preventing children from laboring in an actual slurry of carcinogens was a good thing. You might wonder, as I did, why it took so long to see the light on this one? Well, have you considered that some people were Pro-Dangerous-Child-Labor at the time? Who was in that camp? More people than there should have been. Insurance companies of the time defended the child labor practices because they did such a good job of sacrificing themselves for cleaner chimneys. There were some mechanical devices suggested to do the job instead of kids, but the companies felt more fires resulted in the chimneys NOT cleaned by children so this was a hit to their bottom line. And have you considered the problematic but lucrative partnerships between the orphanages, parishes, and master chimney sweeps of the time? Master sweeps were paid to take on “local strays” and give them gainful employment and often sourced their employees from orphanages and parishes. I can only imagine the world of horrors that unfolded in those relationships. Lastly, there was some description of public perception that, while shortening the life spans of many of the youngest and most vulnerable members of society was regrettable, it had to be weighed against the dangers to society of having chimneys catch fire more often. I can almost respect the cold logic of that position, but I have to say I’m firmly in the camp of looking for solutions that don’t involve increasing child mortality, I don’t know about you guys. Finally, I wanted to wrap up with a brief tour of Pott’s other contributions to medicine. I mentioned that he has many, many things named after him. I wonder if you guys remember some of them? Pott’s eponym collection Pott’s Spine (aka Pott’s disease) - Tuberculosis infection of the spine and all the associated complications such as “cold abscesses” Pott’s Fracture - Ankle fracture of distal fibula that allows subluxation of the talus laterally since medial ligaments are wrecked. We’ve probably all treated this. He’s considered to be a father of orthopedics as well. Pott’s Gangrene - Basically gangrene caused chronically by end artery disease of the legs. Pott’s Puffy Tumor - Not a tumor but rather the word for swelling. Subperiosteal abscess due to frontal skull osteomyelitis. Sinusitis complication. Forehead swelling, fever, headaches, nasal discharge, possible increased ICP. Apparently wrestling is listed as a risk factor due to punches to the head? Sources: -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1037746/?page=1 -http://www.whonamedit.com/doctor.cfm/1103.html -https://en.wikipedia.org/wiki/Percivall_Pott -https://en.wikipedia.org/wiki/Worshipful_Company_of_Barbers -https://en.wikipedia.org/wiki/Chimney_sweeps%27_carcinoma -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1008067/figure/F2/ (Chimney Sweep Pic) -https://www.historic-uk.com/CultureUK/History-Boy-Chimney-Sweep/ -https://www.ncbi.nlm.nih.gov/books/NBK538331/ (Pott’s Disease) -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531910/ (Pott’s Fracture) -https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1008&context=dacosta_modernsurgery (Pott’s gangrene) -https://www.ncbi.nlm.nih.gov/books/NBK560789/ (Pott’s Puffy Tumor) Dr. Max Doctor with a mustache Imagine you’re working the day shift at Bellevue Hospital in New York City–incidentally, since this is a history podcast, the oldest public hospital in the US. It’s hot outside, and it’s Monday, so we all know what that means–plus, let’s give you a little hint that this case isn’t that recent, so, you’re dealing with your standard poor sick person dumps, about six of them, from outlying private hospitals, when the ambulances bring you a case…a young, professional woman is brought in from one of the office buildings near-by with severe stomach pain. The ambulance crew says she was fine this morning, but now she’s got severe cramping pain, and severe gastric emptying. She says she has some tingling in her hands and feet as well. Blood pressure’s low, heart rate’s high…what are your thoughts? Step one–questions from Max and Mike mortality from abdominal pain in general–higher than chest pain gastric emptying and pain out of proportion–mesenteric ischemia, cases in the literature of ‘sudden gastroenteritis’ Step two–escalation You’re just one of the lowly house officers trying to take care of this sick patient at Bellevue, but then you notice a commotion and ask your senior what’s going on. Apparently there’s an office building about eight blocks away that’s in a bunch of trouble; while you’ve been caring for this patient, two more ambulances at least have come from the same place, with patients that have the same symptoms. There are many people sick, all with vomiting and diarrhea. Does this change your differential? How so? Let’s say it’s the early 20th century, so, no joke, your boss at Bellevue says, how about we grab the stomach pumps and go take care of these people in the office building itself? Sounds great! The stomach pump, as a brief aside, was invented by Alexander Munro Secundus–Secundus to differentiate between his father, Alexander Munro Primus, and his son, Alexander Munro Tertius, all of whom held the chair of Anatomy at the University of Edinburgh in the 1700s. Munro Secundus was the most highly regarded, and, in 1767, along with the thinking of the time which fixated on emptying the bowels in one way or another, he invented the stomach pump, which is literally a hydraulic device about the size of a clarinet attached to a rubber tube that is used to manually empty the stomach. Gentleman, have you ever pumped a stomach? These were still in use into the last century; in this case, somehow or another it became clear that there was a huge emergency going on at this office building, with people literally on every floor just emptying themselves, and multiple teams of doctors running around with stomach pumps performing ‘patient care’ (in air quotes). Once the dust cleared, six people were dead, and dozens had become sick, with one of the deaths the original ‘index case’, as it were. What could have possibly happened? Thoughts? The doctors on scene, once done administering care, compared notes, and the medical examiners and so on started to get involved and try to piece together what had happened. They were able to compare notes to the point that the found a common thread–all of the people that got sick had eaten at a local restaurant. Lunch counters and small diners were used frequently at the time and probably still are, and a small restaurant called the Shelbourne proved to have served lunch to all the people that got sick. The first woman who got sick, Lillian Goetz, was a stenographer who had a traditional lunch of tongue sandwich (omigod), coffee, and a slice of huckleberry pie. Although I would suspect the tongue sandwich, it proved to be the pie that was the problem; upon testing, the pie crust revealed traces of arsenic, not present in the flour or any of the basic ingredients. They concluded that is was foul play, and the incident was later known as the Shelbourne Restaurant murders–after those who got sick, the Shelbourne was another victim, as it soon closed, and it was said restaurants around the city couldn’t sell Huckleberry pie to save their lives. Arsenic has been on the pod before; white arsenic, which is a metallic powder, was used for ages as a poison mixed into drinks or food, toxic at low doses. Arsenic dissolves completely in water, and 90% of it is absorbed; it achieves peak concentration within an hour, which is really fast for something we eat or drink. Arsenic attaches really strongly to multiple enzymes in the body–enzymes are like little folded proteins that do stuff–and essentially suffocates cells internally so they die, all over, and then also happens to prevent sugar from being either absorbed or made, which is our back up energy system. It’s absorbed first and most in the guts, and then the liver, which causes the symptoms; because of the way it works, those body systems shut down, which is the main cause of death. Also, which such severe emptying, severe electrolyte abnormalities occur, and when your body gets super low on potassium or magnesium, for example, it’ll short-circuit the heart sometimes. Obviously that’s all a gross oversimplification. This case was never solved with regards to the actual poisoner, but the fact that it was proven as arsenic poisoning at all owes to the story of two men who were instrumental in modernizing forensic medicine, especially in New York. It was overall not unusual at all that a poisoner walked away unscathed and was never caught, especially around this time. New York in the early part of the 20th Century was awash in poisons and not really up to speed on toxicologists or medical examiners. A lot of this episode and the story of early forensic medicine in New York is covered really well in a book called ‘The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York’, by Deborah Blum, which came out in 2011–we’ll link it in the show notes. Prior to around 1917, medical examinations in New York were undertaken by coroners. There were not really stringent requirements for the job, and they got paid on commission based on examinations they did. Given politics at the time, which centered on Tammany Hall, famous for corruption, the coroner’s post was a revolving door of undertakers, politicians, and various other odd jobs; they also produced death certificates that listed the cause of death, and they worked on commission, so it was pretty easy to see how this got co-opted. There were some other famous cases that put this in the spotlight–one chloroform case detailed in the book involved like a string of contradictory experts for days–and prosecutors would routinely avoid calling the coroner for murders because the testimony was so hit-or-miss. So around 1917 the state government passed a law that medical examiners had to be qualified; a man named Dr. Charles Norris was second among three qualified applicants, and was the head of laboratory science at Belleview. The transition was NOT smooth; machine politicians in New York City wanted to use the medical examiner job as patronage, just like they had before, and tried to appoint their own applicant. Then, when there was uproar, they actually tried to arraign the three formal applicants including Dr. Norris for violating a law regarding autopsies. At the time, cadavers were supposed to go to medical schools; by performing the autopsy that was required for the medical examiner’s test, the mayor’s office accused the applicants of breaking the law. This bold-faced power grab didn’t work; the mayor at the time chose Norris because he was second just as a last objection, and, luckily for all of us, chose a famously dedicated man who would go on to be known as one of the two dads of forensic toxicology in the US. Norris was famously dedicated, and often spent his own considerable inherited money on the office of the medical examiner; he was motivated by the old romantic belief of public service that sometimes shows up in the Gilded Age, and lived and breathed the improvements in the medical examiner’s office, along with Alexander Gettler, a pioneering chemist who happened to work at Bellevue as well. Gettler had an opposite path to Norris, immigrating from Austria-Hungary at the age of 7 and coming up through Brooklyn to get a doctorate at Columbia. He literally had to invent many of the toxicologic tests that the early medical examiner’s board used, and worked for decades with the office. Sources:
Dr. Aaron Silver Fox Doc Cardiac procedures we take for granted had to be developed by somebody, somewhere. I don’t know how many times Mike or I have had a patient come to the ER having chest pain, diagnosed a “heart attack” knowing that some part of the heart needed more blood flow, called a cardiologist and had that patient whisked out of our department and onto a cath lab table within literal minutes, to have their heart plumbing fixed without surgery. It can certainly be more complicated than that depending on the scenario, but it was not always this way. One of the interesting things that is discussed early in this chapter, is the fact that the heart was something of an afterthought or organ that was of less scientific interest in the 19th century, and it wasn’t until the 20th century that we made significant developments here. It wasn’t until 1912 until an internist named James Horrick even speculated to an assembly of physicians that blockage of the coronary arteries was probably a thing explaining sudden apparent death. Why did it take so long to figure this out and how was his theory received? (We can discuss some basic cardiac circulation and physiology here). “Myocardial infarction,” the medical term for heart attack, was not really coined until 1918. 1929 - Werner Forssman boldly plays with catheters. Can you tell us a bit about this story and what the concerns of his colleagues at the time were? 1958 - Dr. Mason Sones at the Cleveland Clinic decides the venous system is too easy to put a catheter into. Can you tell us how his first foray into the world of sticking catheters into the arterial side of circulation went? Would you say swimmingly or no?
Once the ability to get catheters into arteries was established, how did we figure out how to fix the problems that were found? This could include a thrombus or blood clot, or a narrowing of the artery due to fat and calcium deposits in the walls (called plaques). I think this involves explaining what the verb “Dottering” is because, whether I was supposed to or not, this part of the book made me laugh. I’m not a fan of balloons–too whimsical and noisy for my taste–but they are quite important to the history of cardiac intervention–fixing problems within the plumbing of the heart, especially. Can you explain what balloons have to do with saving lives?
Any time medicine can fix a life threatening problem without sawing through a ribcage under anesthesia, I’m all for it, but before balloons and catheters were used, one of the only options for fixing artery flow problems to the heart was surgical. Still in use in the right circumstances, “open heart surgery” is the term for going into the thoracic cavity and literally tying in new pipelines to the arteries of the heart, now typically using a big vein taken from the leg, the saphenous vein, to make nice new piping. It took a lot of steps to get to this point because, well, it’s hard to do surgery on a moving organ, especially when it’s kind of important to one’s life. What were the baby steps into cardiac surgery, so-to-speak?
Under ideal pre modern circumstances, I believe I read it’s about a 4 minute window to do procedures on the heart. Maybe 12 minutes with hypothermia. Now we can open a heart, replace a valve, ask poor medical students a bunch of questions until they sweat through surgical smocks while observing, and then have plenty of time to close. What made this possible and how was it discovered?
The last frontier of this chapter, fittingly, is heart transplantation. We can now take a heart from one person and give it to another in need. Can you talk about the first surgeons to figure out the steps necessary to do this, Drs. Christian Barnard and Dr. Norman Shumway? Max Doctor with a mustache. |